Column: Excluding APD Runs Counter to the Goals of Health Reform

Alice Peck Day Memorial Hospital has received a number of inquiries from patients who are concerned about their ability to continue to receive care here. Their confusion arises in connection with the recent flurry of Valley News articles regarding the imminent launch of the New Hampshire health insurance exchange, the state’s switch to a managed care program for the Medicaid program and Harvard Pilgrim Health Care’s announcement of its new ElevateHealth insurance plan. I am taking this opportunity to dispel some of the current misunderstandings regarding these plans and APD.

If I have health insurance through Anthem, is APD now out-of-network?

If you currently are covered by Anthem health insurance through your employer and there will be no change in that plan when the insurance exchange becomes effective on Jan. 1, there will be no change in your relationship with APD. We will continue to be in-network for employer health plans and individual plans that have qualified for “grandfathered” status under the Affordable Care Act. Employers and health plan administrators can confirm if a plan has met the requirements to be grandfathered.

The only Anthem plans that will treat APD as out-of-network are those offered through the health insurance exchange for individuals and the Small Business Health Options Program (SHOP) for small employers. If your current coverage changes to a plan offered through the exchange, you should be sure to familiarize yourself with the new plan. It is a patient’s responsibility to be aware of the provider network available and the potential ramifications of receiving care outside of that network.

If I am covered by an Anthem plan through the exchange, is it true that I will no longer receive care at APD?

No. You can continue to receive care at APD, but should be aware that APD will be out-of-network, so your copayments and co-insurance responsibilities may be higher. Again, it is important to fully familiarize yourself with your new plan and what your copayment and co-insurance requirements will be for in-network and out-of-network providers. For example, a doctor’s office appointment may result in a $15 copayment charge from an in-network provider but a $25 fee for an out-of-network provider.

Why was APD left out of the network? Was it a quality-of-care issue?

No. Anthem’s decision to leave APD and many other facilities out of its network had absolutely nothing to do with the quality of care. The state required Anthem to prove that its network was adequate for the insurance plans it will offer on the exchange. Anthem told APD that its decisions about which hospitals and physician practices to include were based on having the fewest hospitals possible while still serving all regions of the state. The New Hampshire Hospital Association recently identified APD as the critical access hospital in the state with the highest quality ratings. Moreover, New Hampshire Hospital Association data have shown that APD has been one of the two lowest-cost hospitals in the state for the last several years.

We think the decision to exclude APD from this network for purely geographic reasons is extremely shortsighted: It will direct patients away from a high-quality, low-cost facility, which is contrary to the ACA’s goals of increasing access, improving quality and decreasing cost. APD’s exclusion, in fact, may result in just the opposite — decreasing access and increasing cost.

If my employer purchases insurance through Harvard Pilgrim Health Care and its ElevateHealth program, can I still use APD for health care?

Yes. APD will continue to see all patients who seek services here. However, the ElevateHealth plan, unlike Anthem’s plans, is a closed network. This means that if a patient seeks care at a provider that is not in the ElevateHealth network, the patient will be liable for 100 percent of the cost. ElevateHealth has no provision for out-of-network payments. ElevateHealth patients will be required to obtain care through one of the plan’s providers or pay for those services wholly out of pocket. APD will ask all ElevateHealth patients to sign a waiver prior to receiving services acknowledging that their health insurance plan will not cover APD care and the patient accepts full financial responsibility. APD will continue to be an in-network provider for all other Harvard Pilgrim insurance programs. As mentioned earlier, it is the patient’s responsibility to know what provider is in-network and out-of-network and make choices accordingly.

APD’s primary mission is to have all patients receive high quality care at low cost. It is also important to us that all residents in our region are fully informed about the changes in the health care industry that may affect them.

Susan E. Mooney, M.D., is the president and CEO of Alice Peck Day Memorial Hospital.